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Date run 9/26/2014 11:49:10AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/26/2014 <br /> Record Selection Criteria: Facility ID FA0021704 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 2 SSN/Fed Tax ID <br /> Owner ID OW0011971 New Owner ID <br /> Owner Name REHAB FOCUS HOME HEALTH INC <br /> Owner DBA <br /> Owner Address 1503 W MARCH LN A <br /> STOCKTON, CA 95210 <br /> Home Phone 209-472-7005 <br /> Work/Business Phone Not Specified <br /> Mailing Address 3340 TULLY RD STE C-8A <br /> MODESTO, CA 95350 <br /> Care of REHAB FOCUS HOME HEALTH INC <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021704 <br /> Facility Name FOCUS HOSPICE <br /> Location 1503 E MARCH LN <br /> STOCKTON, CA 95210 <br /> Phone 209-507-7272 <br /> Mailing Address 3340 TULLY RD STE C-8A V� �SS'7 �C✓ 1� .�. <br /> MODESTO, CA 95350 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039376 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name FOCUS HOSPICE (Circle One) <br /> Account Balance as of 9/26/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PR0537671 EE0003973-ROBERT MCCLELLON Active Y N A 0 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment T pe Check Number Re d by <br /> REHS: ����i Date—10_/�,_/ / _ Account out: Date a/Z01 <br /> COMMENTS: <br />